My husband likes to tell the story of his old childhood friend whose fourth grade teacher found him a bit too restless in the classroom. One day after school, she told his mother to tie him into a chair at home to teach him how to sit still. The mother, being a rather enlightened educator in her own right, immediately put her son into a more progressive school. Problem solved. The mother simply changed her son’s environment, rather than trying to change him. Today he is a successful musician.
Child psychiatrist Dr. Kevin Kalikow, assistant clinical professor of Child Psychiatry at New York Medical College, with a private practice in Mount Kisco, brings the same kind of wisdom to his new book, Your Child in the Balance—An Insider’s Guide for Parents to the Psychiatric Medicine Dilemma (CDS Books/Perseus Books Group, $22.95). His book poses the question: “Is medicine the best treatment for your child?”
Using a reader-friendly approach, Dr. Kalikow presents a factual discussion, highlighted by vignettes to help parents reach an answer. First and foremost, he stresses the necessity of careful evaluation of the child’s history and symptoms by a physician, as well as an analysis of all the risks and benefits of medicine compared with those of alternative treatments, including no treatment at all. In short, this is a book many parents have been waiting for.
After explaining the basics of brain dysfunction — and how diagnosis is reached — the interaction between environment and behavior, and where psychopharmacology enters the scenario, Dr. Kalikow asks, “How smooth should a childhood be? How easy should parenting be? When do we learn from trying to manage adversity?” Parents have to find a balance between accepting their child and changing their child, with the goal of helping that child control his pain and reach his potential. Sounds like a tall order, and it begs the question: How do we define our child’s “potential”?
Dr. Kalikow states, “Every child has strengths that should be noted and supported without allowing his/her weaknesses to excessively lower his/her sense of self.” While the types of potential among children differ, and while some take longer to present themselves than others, parents should not limit the definition of potential to academics, he urges. “Parents should not use grades as a measure of potential or lack of it. Some children attain grades below their intellectual capability — sometimes because of an underlying psychiatric disorder (like ADHD or depression), which needs treatment; and other times because they have simply not matured to the point that they see why grades are important. In time, many of these children will learn that today's effort often translates to tomorrow's success; but this can take years and parents must learn to be patient.”
That kind of patience may be hard to muster in today’s climate of higher stakes placed on academic achievement. Dr. Kalikow acknowledges in his book that, “As a tool of change, medicine challenges parents to decide whose demands their child should meet. When is it better to conform to the demands of society, and when is it better to accept one’s self as is?” With the increased value placed on academic success in our society, “it seems more justifiable to use medicine to improve a child’s school performance” if inattention is interfering with that performance and if it is treated as a symptom and not just a characteristic.
The number of prescriptions for stimulants (and antidepressants) more than tripled from the late 1980s into the late 1990s, and today 2.5 million children take stimulants, mostly to treat attention deficit hyperactivity disorder. A federal advisory panel recently issued warnings about the dangers of stimulants like Ritalin, after being directed by the FDA to evaluate their possible cardiovascular risks. Dr. Kalikow’s response to this latest warning is, again, the critical need for parents to weigh the risks against the benefits of medicine with the help of a trusted professional. “In this case, the risk seems very small… less than the overall mortality rate reported for all (not just stimulant-taking) one- to 19-year-olds. Nevertheless, any risk, even the smallest, is too high relative to no benefit. So, parents must weigh any risk against the benefit they think their child is receiving from the medicine, and then decide.”
Dr. Kalikow addresses the role of stimulant medicines (and Strattera) in increasing attention span in the school environment. “It’s complicated because we don’t want to overly generalize. Some children benefit enormously from these medicines in that the medicine allows them to function to their potential. However, other children are given medicine to help them focus in an educational system which plays to their weakness. I believe that some, not most, of these children might not need medicine if they were learning tasks that played to their strength. Our education system puts a premium on reading, writing, sitting for long periods and listening. Less academic emphasis is placed on visual spatial skills, construction skills, interpersonal skills, and the like. Some of these children stop taking medicine when they move on to an educational environment in which they can exercise their assets.”
This falls under #2 of Dr. Kalikow’s Ten Commandments of Medicine: “Before jumping to medicine as the answer, ask whether changing your child’s environment would be helpful.” Which brings us back to the boy whose teacher wanted him tied to a chair. What would a parent do today in a similar situation? Granted, it is unlikely that a teacher now would ever suggest bondage in the first place. But now that parent can reach for Your Child in the Balance to help figure out what to do. Dr. Kalikow is a voice of reason amidst a sea of worried parents, and his book should help quell parents’ fears and answer their questions.